Staley Implementation Group Meeting                 Previous Meeting Next Meeting
Official Minutes
January 28, 2005

Participants:

Judy Cunio, Kristine Merrin (Judy’s assistant), Marcie Ingledue, Bev Herrin, Cynthia Owens, Caryl Knudsen, Joanne Fuhrman, Lynn Greenwood, Tom Giles, Jim Wrigley, Arlene Jones, Bill Lynch (facilitator), Molly Holsapple, Tim Kral, Mike Maley, Barrie Brewer, Howard Klink, Tara Asai.

Families and self-advocates met for their pre-meeting from 8:30 AM – 9:30 AM.

Meeting was called to order by Bill Lynch, facilitator, at 9:44 AM.

Introductions and Updates

Kathryn Weit and Dan Peccia could not attend due to sent their regrets. Mary Lee Faye was also unable to attend.

Review and Approval of Minutes

Joanne Fuhrman motioned and Caryl Knudsen seconded approval of the minutes. Minutes approved.

Monitoring/Updates

Brokerage

Bev Herrin reported on a memo written January 7, 2005 by brokerage directors to the state addressing issues of concern around paperwork and caseload sizes, and a time study conducted at four of the brokerages. Two concerns determined by the paperwork reduction workgroup were: (1) the process and time involved in changing a plan seemed overly cumbersome resulting in delays to customers being able to use plan dollars according to their wishes, and (2) crisis referral (statewide category 1 crisis referral) consumes a lot of PA time, so as caseload increases, this process may become more problematic.

Counties and state were asked for input. Counties have not had enough time to read the memo and comment, but counties are looking at streamlining activities. Question was asked as to how many of the crisis referrals to brokerage end up entering comprehensive. Some of this information is being pulled together by Mike Maley and will probably be available at the next SIG meeting after review by the Staley Negotiating Team.

Results of a time study conducted at four of the brokerages showed that PA’s are spending a lot of time on paperwork—almost half of each day. These results if compared to a similar time study conducted by SDRI the previous year indicated an increase in percentage of time spent on paperwork and a decrease in actual time spent with customers.

Recommendations from the brokerage include: (1) brokerages will continue to advocate for a lowering of caseload size, although they realize that this is not achievable in the current state budget situation; (2) an increase in the budget so that the customer: PA could be reduced from 1:42 or 43 to 1:38; (3) ways to accommodate changes in customers’ plans that are more streamlined, such as state’s consideration of increasing the threshold percentage for customer plan change dollars needing county authorization from 10% to 40% and at the same time allow counties to be able to bill state for plan review in addition to the authorization. According to Mike, the state can examine this as the 10% value was set at inception of the brokerages.

The state has asked the brokerages to fold in the PC 20 program individuals in the next few months. PC 20 is a Medicaid program where the state has paid funds to individuals who need assistance with “Activities of Daily Living.” Concerns were raised by brokerages and families. Brokerages will not be receiving COLA, and have estimated that there would be an increase in customers needing FI funds from the 30% (currently) to 50 %. Brokerages would need to conduct criminal background checks and certification of providers as domestic employees. The state is not allocating funds to cover operating costs. Mike explained the brokerage operating fund methodology. Recommendation was made for a formal resolution from the brokerages stating that the anticipated PA:Customer ratio of 1:45 expectation is too high and that the model budget is flawed.

Question was asked as to whether the state wants to take back administrative dollars from the brokerages. Mike’s response was no. Cynthia Owens commented that if the state is continuing to add more responsibilities onto the brokerages and increase caseloads, while not increasing funds, the system will be compromised and fall apart.

Brokerages again emphasized their concern about the roll out schedule and the need for brokerages to increase their original contracted numbers to serve more people, but without the addition of another brokerage. Previous recommendation by the SIG had been the addition of another brokerage versus increasing numbers into existing brokerages. Mike stated that it is up to each brokerage to decide if they want to increase customer numbers or not. Comment was made that determining factors for increasing or not increasing customer numbers should be based on customer outcomes.

Tom Giles posed the question as to whether there was any formalized data on best practices within the brokerages. He would like to see the brokerages gather that information and include it in the brokerage report.

As the end of the Staley rollout is approaching, the SIG will need to do some strategic thinking around capacity and next steps.

County

Lynn Greenwood reported for the counties. Caseload size is a big issue, for Lane County there was an increase from 77 per service coordinator last year to 112 per service coordinator this year. Other issues include concerns around family support which had been cut back so much last year; holding the line on crisis and diversion budget; cuts in OHP and how that will affect other county services; and provider instability with lack of COLA’s. Counties are now dealing with two different rate structures and conversations are occurring with providers about the levels. Comprehensive Intensive Support rule is coming up with some challenges in ensuring that the right safeguards are in place. There is nothing in rule in regards to the family being the correct entity to provide case service decisions for an individual. There is work being done around referrals of people in crisis, protective service issues, and reporting. In Lane County, monthly meetings are conducted with PA’s on best practices. Lynn did not know if this was occurring in the rest of the state. Molly Holsapple noted a growing concern of counties being able to work with providers and VR.

Customer/Family/Self Advocates

Families would like to ask brokerage directors three questions around staff retention—(1) In the past year, have the brokerages seen a problem with staff retention? (2) Demonstration of supporting data. (3) If staff have left the brokerage, why?

Families would like more information about the comprehensive in home supports rule and any changes that are occurring. Although preliminary discussions are occurring with Jesse Martin as the staff point person, a rule workgroup will be set up before a rule change is made. Clarification of policy on in home comprehensive rule is being sought from Mike through Jesse. Families are making the recommendation that there be family and self-advocate representation in the workgroup. A planning group will come together for SILP as a separate implementation group.

Provider

Tim Kral reported that providers would like to continue to advocate for the COLA since it was originally in the state budget, but at this time is not being given. Meeting has occurred between brokerage and providers to build relationship.

SPD Update (Mike Maley)

Budget—an understanding of the governor’s budget is being formulated at this point and data is being gathered in preparation for the Ways and Means Committee meeting. Important are the decreases in OHP (absence of dental and some therapies) and how does this relate to waiver programs. Question was asked as to how much are the total dollars of COLA for DHS. This question was not answered as Mary Lee Faye was not present. It needs to be remembered that certain assumptions were made in crafting the budget.

Legislation—all bills have been distributed, analyzed and prioritized.

There is a workgroup to ensure that supported living and SILP individuals are truly identified.

Waitlist workgroup (Christine Duffy, state staff) has met a couple times. Work that is being done will help in planning for 2007-2009. Seeks to build on what is already available electronically, so that counties will not have to repeat information. Group is in the process of developing parameters to be used, such as an individual would need to be actively case managed in order to be on the waitlist.

Another workgroup will be to frame issues and approaches, and define rate restructuring. Family support.

Staley Report—(handout) no questions or comments were received about the report.

Brokerages were asked by state for information on (1) annual plan costs, (2) who is receiving above base and why, and (3) who is receiving PC20. During this third reporting period, more consistent information is being seen. Planned expenditures continued to average $650 per month with actual expenditures averaging $550 per month. 7% of plans qualified for Base Plus with five on a 365 day grace period. PC20 amounts to 40% of individuals enrolled and includes those who did not have a plan yet but were receiving funds from the state. This is consistent statewide. Greater than 80% of the brokerage customers in the >$9600 per year level were using PC20.

Priority Work Areas for 2005-2006—(handout) 7 focus areas for adult support services were identified by the state:

• eXPRS System: a new business billing and payment system to replace the antiquated CPMS system is just starting;
• Service Provision:
• Administrative: can we tag a family member as a domestic employee;
• Individual Service Delivery—more clear goals, tying-in to quality assurance;
• Rules, Policies, and Procedures—
• systematic assessment of what was written;
• rewrite of expenditure guidelines; look at what other states are doing; format
• “decision making tree” for allowable expenditures—what is appropriate for one plan and not another depending on a customer’s individual situation or needs;
• rate guidelines implementation—data around exceptions, where are the expenditures falling (highs and lows);
• Health and Safety
• what are those supports and training that we have not provided for in the past;
• be able to use other supports/services already existing in the system (relationship to other SPD services for possible support);
• Strategic Planning: 2005-2007 and 2007-2009 enrollment projections and brokerage capacity needs; coordination activities with other partners such as education;
• Communications
• Stakeholder Relationships: brokerage-county roles and relationships—although there is a need, no billing structure exits at this point; brokerage-provider roles, responsibilities, and relationships--documentation and retooling;
• Quality Assurance: would like to achieve a monthly process that is repeatable and consistent; in regards to SPD field reviews, would like to have improvement in the fundamentals around documentation (the draft is finished) in three areas—(1) payments to brokerages DD 149 are based on contracted amount per month and not routinely paying out to actual (to the amount of $5 million), (2) cash flow will need to be monitored, (3) CPMS billing does not work for what brokerages are doing, as billings are made to Medicaid; internal controls of brokerages were found to be imperfect. Now need to craft a written response too the DHS internal audit. Mike will find out how to get a copy of the document to the SIG.
• Benefit Levels: need to get the numbers on implementation of Mid-Base Plus level as soon as possible—Molly commented that the estimates from the brokerage were pretty accurate, but some customers are in fact reaching the criteria for full Base Plus. There is concern for dual waiver individuals who may not meet the mid-level funding. There are two individuals who are ineligible. Implementation of PC20 integration—state is looking at completion of the integration process sometime in June 2005 instead of March 2005. Looking for meaningful, incremental strategy for this, as there are concerns about workload and compensation.

Brokerage directors are to look at these items and to develop plans around.

Budget and enrollment process—the Governor’s original plan had 0 enrollment during the first year of the biennium and 1000 in the second year. The present plan is for 300 during the first year and 700 in the second year, with a delay during July-October for SILP enrollments and 18 month period delay in Comprehensive, which should be able to cover costs. Enrollment history for the 2003-2005 biennium is 340 individuals in the first year and 600 individuals in the second year. The dilemma is how to distribute the 1000 individuals by county. The criteria used previously will not work. Lorraine Burgeo is working on a process which will use the adult population of case management dollars to make determinations.

From February 2005 through June 2005, brokerages will enroll an additional 100 customers. This is to backfill for terminations. Five counties will not receive any additional individuals as 100 was divided by the percentage termination for county.

Top Strategic Priorities

Rate Issues

Molly reviewed the new absenteeism policy with a power point presentation and handouts on limited monthly billing, to provide a balance between customer budget and provider costs when the customer is not attending as planned. Monthly billing is for those customers whose average attendance absence reaches 20% or more for 3 months, and agree to the plan. The policy assumes a history of attendance, which can be tracked retrospectively. For a new customer to be engaged in this policy, would require 3-4 months of attendance. The policy had a review process, and could remain in effect as long as needed. There are six requirements for monthly billing. Tara Asai asked why this does not apply to independent contractors. Reply was the lack of baseline data. Some expressed that this strategy should be followed for independent contractors.

Molly would like input so as to move ahead with this policy, with implementation starting in March 2005 and completed by the end of April 2005. Discussion followed on various points of the policy. The 20% was arrived at as a best guess. The policy is open for evaluation and reassessment, which could be supported by provider analysis and invoicing. Customer education with an agreement up front and in writing is being assumed—informed choice, clear communication, and understanding. An example invoice was included. The state is not requiring an invoice, but is requiring the content (of an invoice). Besides the usual content, the reason for absence needs to be cited, which would give the customer, provider, and PA, information for problem solving. Optional is the progress note. Judy Cunio questioned whether money was being wasted. The reasoning for development of this policy was revisited. Customer being able to have a copy of the bill and importance of signatures were listed as important so as to prevent providers billing for things not needed or asked for.

Conclusions at the end of discussions yielded: (1) the 20% value could be changed depending on review of the data 6 months after full implementation; (2) position on usage with independent contractors is “no;” (3) implementation would be in March and April 2005, where brokerages and providers would implement as a strategic plan; (4) the invoicing would be a major workload issue for providers and somewhat for brokerages.

Order of Enrollment

Staley Negotiating Team is concerned whether the numbers and patterns for 04-05 enrollments will cause the same issues as arose in 03-04. Issue revolves around the number of students coming out of high school piling up due to brokerages only being allowed to enter four customers per month. State will look at last year’s data to see if a determination can be made. If enrollment continues to have high school transitioning kids as a priority, concern is also around funds going towards VR.

For the aging caregiver category, will need to re-examine the age threshold and distribution. In previously defining of this category, family relationship dynamics had been under looked.

Quality Assurance

Field Review Update

Tom Raccopio reported on the field review conducted of all the brokerages. Customer files were examined (at least 1 person represented by each brokerage) for HCBS waiver consistency. The goal of this review was to establish baseline values. Criteria used to evaluate each file are stated in the Report Summary and Discussion Points Support Services Field Review Findings document. In future field reviews, these criteria will remain the same. An example of the methodology used was given. Brokerages were happy to receive the information on what was okay and what was quality. Each brokerage was found to have strengths, but these strengths were not exhibited across the board. There were excellent plans and also those which needed work.

Areas of concern identified were with provider information and safety planning. As this field review was for development of baseline, a set of future benchmarks was established for comparative adjustment. The document should be looked at as a working document. Concern was raised about reinforcing the view that paperwork is important. Different views of setting benchmarks were stated briefly. Discussion followed. In conjunction with the benchmarks, a policy/training tool was developed. All items listed on the tool were considered important with individual items marked as either needing additional policy clarification or comprehensive training. {There should be “x’s” under “Comprehensive Training” for items, “Job descriptions and contracts for providers are not personalized to the individual,” and “More comprehensive outcomes and progress reports from providers.”} The goal is to achieve real outcomes from the field reviews, which would be part of future steps.

SIG was asked to agree on the 2005 benchmarks, with the understanding that the benchmarks would be reviewed. Agreement was reached by consensus.

Consumer (Customer) Satisfaction Surveys

Vicki Storie summarized the results of the customer satisfaction surveys for FY02 and FY03. Not all of the results received from FY02 were through use of the official survey version. ore use of the official version occurred in FY03. It would be best to have standardization of the survey. In general, it is not known if actual, usable information can be obtained from this survey, as QA is looking for solid core questions and program questions. State is asking HSRI and stakeholders group to evaluate.

Discussions followed. On-line survey methodology was suggested so as to end up with a greater return on survey responses. Another suggestion was made to conduct the customer satisfaction survey throughout the year coinciding when ISP’s are done, which was found to increase response rate. Sensitivity to language and other communicative modalities was brought up. Customer education should increase response rates.

Recommendation was made that some of the narrative comments be included with the summary report. This would need to be obtained from the individual brokerages.

QA seeks to develop a satisfaction survey that is user-friendly and applicable across all of SPD, which initially would be tried on a sample basis. May incorporate the use of interviewer and technology modalities.

Guide to Supports for Adults with Developmental Disabilities

Work has begun to gather information for this user-friendly guide for families, PA’s, and providers. Cynthia explained that the intent would be similar to the IDEA guide that was developed for special education by OAC. In trying not to be cumbersome, the document would contain a lot of links to information including eligibility through county services, then onto brokerage, what to expect with transitional services in high school to employment.

State had said that this was a recognized need that should be funded. Work and production, including translation costs would be handled by state. Mike stated that Staley will pay copying costs for production of the first 1000. Cynthia requested that any information to be included in this guide be sent to her electronically. Judy is willing to help in this endeavor to make sure it is user friendly for self-advocates.

Quality Assurance Plan

Comments will be taken on the Quality Assurance Plan and the revised plan with changes will be sent electronically to Kathryn and Bill. SIG asked Vicki for a pictorial overview of the status of different parts of the plan and the interrelationships.

Waiver review data and summary will be presented at the DD Quality Advisory Committee

meeting on February 25, 2005 from 9:30 AM – 12:00 PM. Joanne will not be able to attend, Bill will go instead. Bev will also attend, representing brokerages.

Migration of the support services website to a DHS site is projected for February 8, 2005. The site will contain the waiver, waiver fact sheets, QA plan, and downloadable reporting sheets. Completion of the website should occur in the next few months.

There have been eight contested cases. Vicki can report on these at the next SIG meeting. The challenge faced is in defining what a grievance is and to what level(s) do we want to identify.

Set Agenda for March 25, 2005

Our next meetings will be held on Friday, March 25, 2005 and Thursday, May 19, 2005 from 9:30 AM – 3:30 PM, with families meeting at 8:30 AM.

Agenda will include:

• More information from Robin Cooper and next steps

—( plan to rewrite the expenditure guide)

• Impact on Rate Revisions
• Order of Enrollment
• Brokerage/County Relationship
• County Report—enrollment process projections on timelines for enrollments (Jessica)

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